What is Oral Herpes?
It has been found that 80% of the population are asymptomatic carriers of the virus, while 20-40% of people have experienced cold sores at some time. The infection is more prevalent in lower socioeconomic groups, with an overall global growth in the last twenty years.
What are the Risk Factors?
How is the Manifestation?
Primary infection: Most often occurs in infancy or childhood. It may or may not be symptomatic. Gingivostomatitis is the most common presentation in young children. It presents with vesicles and ulcers on the tongue, lips, gums, buccal mucosa and hard and soft palates. Pain, inability to swallow, drooling and dehydration are common. There may be associated fever, cervical lymphadenopathy, halitosis, lethargy, loss of appetite and irritability. Pharyngitis is a more common presentation in adolescents, with lesions in the throat associated with viral symptoms similar to those of glandular fever. Herpetic whitlow may occasionally occur via spread to the fingers.
Recurrent infection: Cold sore lesions are the most common form of recurrent disease. They tend to occur in the same location, be unilateral and recur two or three times a year on average. Prodromal symptoms may occur 6-24 hours before the appearance of a lesion and include tingling, pain and/or itching in the perioral area. Cold sores are usually seen on the lips and extend to the skin around the mouth. Other areas on the face, chin, or nose are sometimes involved. Lesions begin as erythematous areas that swell into papules. These become vesicles, which then collapse into ulcers. This takes 1-3 days. The ulcers crust over and the skin returns to normal within about 2 weeks. Oral mucosal lesions are rare and not generally associated with fever. They are usually restricted to small clusters of microvesicles that rupture to leave punctate ulcers, typically on the gums near the roof of the mouth. Immunocompromised people may develop chronic ulcers, often on the tongue.
What is the Management?
Advise to seek medical advice if the person’s condition deteriorates (eg the lesion spreads, a new lesions develops after the initial outbreak, persistent fever, inability to eat) or no improvement is seen after 7-10 days.
What is the Drug Treatment?
Oral antiviral agents: For immunocompetent individuals, oral antivirals are not routinely indicated for the treatment of cold sores but may be indicated in severe episodes only. Seek specialist advice for people who are immunocompromised (including people with HIV). Aciclovir is active against herpes viruses but does not eradicate them. It can be used as systemic and topical treatment of herpes simplex infections of the mucous membranes and is used orally for severe herpetic stomatitis. Valaciclovir is an ester of aciclovir. It is licensed for herpes simplex infections of the skin and mucous membranes.
Laser treatment is also an option for severe breakouts. Low-intensity laser has been used in a patient with severe herpes simplex virus type 1 (HSV-1) infection of the lower lip with rapid relief of pain after one application.
What are some Complications?
What is the Prognosis?
Is there any Prevention?
Aphthous Mouth Ulcers
What are aphthous mouth ulcers?
There are three types of these ulcers. Minor aphthous ulcers are the most common (8 in 10 cases). They are small, round, or oval, and are less than 10 mm across. They look pale yellow, but the area around them may look swollen and red. Only one ulcer may develop, but up to five may appear at the same time. Each ulcer lasts 7-10 days, and then goes without leaving a scar. They are not usually very painful. Major aphthous ulcers occur in about 1 in 10 cases. They tend to be 10 mm or larger across. Usually only one or two appear at a time. Each ulcer lasts from two weeks to several months, but will heal leaving a scar. They can be very painful and eating may become difficult. Herpetiform ulcers occur in about 1 in 10 cases. These are tiny pinhead-sized ulcers, about 1-2 mm across. Multiple ulcers occur at the same time, but some may join together and form irregular shapes. Each ulcer lasts one week to two months. Despite the name, they have nothing to do with herpes or the herpes virus.
Aphthous ulcers usually first occur between the ages of 10 and 40. They then recur but there can be days, weeks, months, or years between each bout of ulcers. The ulcers tend to recur less often as you become older. In many cases, they eventually stop coming back. Some people feel a burning in part(s) of the mouth for a day or so before an ulcer appears.
What causes aphthous mouth ulcers?
Tell your doctor if you have any other symptoms in addition to the mouth ulcers. Other important symptoms would include skin or genital ulcers or rheumatological (joint) pains and inflammation. Rarely, severe mouth ulcers can occur after taking a medicine you are allergic to. Sometimes a blood test or other investigations are advised if other causes of mouth ulcers are suspected.
What are the treatments for aphthous ulcers?
Patients with aphthous ulcers should avoid spicy foods, acidic fruit drinks, and very salty foods, which can make the pain and stinging worse. Use a straw to drink, to avoid the liquids touching ulcers in the front of the mouth. Use a very soft toothbrush. See a dentist if you have badly fitting dentures. If you suspect a medication is causing the ulcers, then a change may be possible. For example, if you are using oral nicotine replacement therapy (nicotine gum or lozenges), it may help to use a different type instead such as patches or nasal spray.
Some medicines may ease your symptoms from the mouth ulcers. Chlorhexidine mouthwash (brand name Corsodyl® or Chlorohex®) may reduce the pain. It may also help ulcers to heal more quickly. It also helps to prevent ulcers from becoming infected. Unfortunately, it does not reduce the number of new ulcers. Chlorhexidine mouthwash is usually used twice a day. It may stain teeth brown if you use it regularly. However, the stain is not usually permanent, and can be reduced by avoiding drinks that contain tannin (such as tea, coffee, or red wine), and by brushing teeth before use. Rinse your mouth well after you brush your teeth as some ingredients in toothpaste can inactivate chlorhexidine. Steroid lozenges (brand name Corlan® pellets or Betnesol® tablets) may also reduce the pain, and may help ulcers to heal more quickly. By using your tongue you can keep a lozenge in contact with an ulcer until the lozenge dissolves. A steroid lozenge works best the sooner it is started once an ulcer erupts. If used early, it may ‘nip it in the bud’, and prevent an ulcer from fully erupting. The usual dose is one lozenge, four times a day, until the ulcer goes. In children, use for no more than five days at a time. A barrier paste or powder such as carmellose sodium (brand name Orabase® and Orahesive®) can be applied to the ulcer to protect it and reduce pain. A painkilling oral rinse, gel, or mouth spray may help to ease pain. Examples include benzydamine spray (brand name Difflam®), or choline salicylate gel (brand name Bonjela®). Bonjela® should not be used in children under the age of 16 due to a potential risk of Reye’s syndrome if it is overused. This is the same reason why aspirin cannot be used in children too. Note: Bonjela teething gel® no longer contains choline salicylate and has been reformulated with lidocaine, a local anaesthetic (to cause temporary numbing).The effect of painkilling medicines is unfortunately short-lived.
You can buy all the treatments listed above from pharmacies without a prescription. Other treatments may be tried if the above do not help or where the pain and ulceration are severe. Examples include, a course of steroid tablets, strong steroid mouthwashes, colchicine, tetracycline or doxycycline mouthwashes, and some immunosuppressant drugs.
When should I see a doctor?
Oral cancer can sometimes start as an unusual mouth ulcer that does not heal. You should see a doctor or dentist if you have a mouth ulcer that has lasted more than 2-3 weeks without sign of healing, or is different in any way. This is especially important if you are a smoker. Your medical doctor or dentist may refer you urgently to the outpatient clinic to see an ear nose and throat (ENT) specialist or an oral (mouth) surgeon. A small sample (biopsy) of the ulcer may be taken in clinic and examined, to exclude cancer.